Pining for Pilates

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October 2007 Biomechanics Magazine

Pining for Pilates

Practitioners back the exercise program for rehabilitation

By: Lori Rochelle Roniger

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Pilates sidetracked Lakis, an instructor in the exercise

discipline, on his path to physical therapy school. A friend

suggested he try Pilates for chronic pain from a lower back injury

he had seven years ago that hadn't responded to traditional physical

therapy and orthopedic treatment. An athletic man who has performed

yoga since age 15 and has worked as a physical therapy aide, Lakis

spent six months undergoing what he described as excruciating pain

until he discovered the exercise system.

Developed by ph Pilates in the early 20th century, the method is

made up of hundreds of exercises that can be performed on mats on

the floor or on specialized machines. A boxer, circus performer, and

self-defense trainer, the German-born Pilates is said to have begun

teaching fitness and exercise to his compatriots while interned at a

camp in Lancaster, U.K., during World War I.

He later moved to New York City and opened an exercise studio that

attracted a significant clientele of dancers. Pilates called his

method " contrology " to indicate the emphasis on muscular control.

The exercise system incorporates attention to breath and muscle

control and focuses on strengthening the body's core, including the

abdomen, lower back, and hips. Pilates shares its focus on breath

with yoga, but its repetitive movements are more in keeping with

active exercise disciplines.

The availability of Pilates classes and instruction for individuals

seeking rehabilitation, pain management, a new exercise regimen, or

enhancement of their sports performance has proliferated this decade

due in part to a 2000 intellectual property lawsuit ruling, which

prevented restriction of the use of the term Pilates. This has

allowed practitioners to more easily advertise their services.

" Many of today's elite athletes utilize Pilates for performance

enhancement as well as rehabilitation, " said Brent , PT,

president of Polestar Pilates Education of Coral Gables, FL, which

trains Pilates teachers. " Built into Pilates is an innate ability to

progress the client from rehabilitation to fitness and finally to

performance. "

Tiger Woods and Venus are said to include Pilates in their

workouts, as do entertainment celebrities Madonna and L.

.

Lakis and other Pilates enthusiasts laud the discipline's

effectiveness at treating biomechanical conditions, strengthening

the body, and improving function by considering the whole body

instead of just an injured joint or body part.

After experiencing the benefits of Pilates, Lakis trained as an

instructor and now operates a Pilates studio, dharmaspace, in

downtown San Francisco.

Some tasks, such as hands-on mobilization of a knee joint, belong

squarely in the realm of physical therapists and not Pilates

teachers, explained Lakis, who still plans to earn a physical

therapy degree. However, for some conditions, like low back pain,

Pilates can be very effective at pain reduction and helping clients

to improve their performance of activities of daily living, he said.

" We teach you how to engage the muscles that support your spine, how

to move with a supported spine, and how to take groceries out of

your car with a supported spine, and how to move and sit properly, "

Lakis said.

He finds that many of his clients, while reasonably active, have

some preexisting biomechanical issues. They may have torn an

anterior cruciate ligament years earlier or are suffering from back

or plantar fasciitis pain. Pilates can be adapted to the conditions

of most bodies, and Lakis even counts a quadruple amputee among his

clients.

Lori -Brown, PT, who has worked as a Pilates instructor for

20 years and earned her physical therapy degree in the early 1990s,

was introduced to the exercise system after sustaining a dance

injury. A doctor told her to wear a brace and warned that she would

never dance again. -Brown ignored his advice and listened

instead to a dance teacher who recommended Pilates. After taking up

the exercise system she was able to resume dancing.

Her work as a Pilates instructor sparked her interest in learning

more about the body. She later completed physical therapy school but

found that she favored Pilates over the physical therapy skills she

had been taught.

" When I went to school for physical therapy, there was a single-

joint kind of focus. It was so frustrating because I could see the

body in a 3D, multijoint way, " she said.

Now -Brown co-owns Pilates Seattle International in

Washington, which also offers physical therapy. Her clients have run

the gamut from a 90-year-old woman who suffered multiple falls to

individuals with multiple sclerosis and those experiencing neck and

back pain.

" Pilates integrates the whole body, " she said.

Practitioner referrals

Some physical therapists and physicians recommend Pilates to

patients following rehabilitation due to pain or injury or following

surgery.

" Where we find the greatest benefit for most orthopedic problems is

where the patient might see the PT for two to four visits for

evaluation, structural work, and the initiation of neuromuscular

reeducation, " said.

At that time, the patient can then begin working with a Pilates

instructor who is knowledgeable about rehabilitation.

" The patient can begin aggressive conditioning appropriate for the

impairment, " he said. " I usually suggest a minimum of two visits per

week, and, for the best results, three to four. "

Jim A. Youssef, MD, a spine surgeon with SpineColorado/Durango

Orthopedic Associates in Durango, CO, typically sees patients

referred from other practitioners after failing nonoperative

treatment.

" I recommend core stabilization conditioning programs for all of my

patients, " he said. He advises his patients to perform Pilates three

times a week.

L. Jaffe, MD, clinical professor and vice chairman of

orthopedic surgery at New York University Hospital for Joint

Diseases, is one of the authors of an introductory article in the

Bulletin of the NYU Hospital for Joint Diseases in June about the

use of Pilates following hip or knee replacement. He learned about

the exercise system from several dancers among his patients, and a

Pilates instructor, Beth Kaplanek, RN, who is a coauthor of the

article.

" They all extolled the virtues of Pilates, " Jaffe said. " I looked

into it and found out that for the most part Pilates was low-impact

and would lend itself to a rehabilitation program in total joints. "

Surgeons at NYU have been recommending Pilates to patients who are

motivated to perform the exercise regimen. The Bulletin article

provides guidelines for Pilates following hip or knee replacement.

However, the authors have not conducted a controlled study of the

use of their recommendations in joint replacement patients.

Brett Levine, MD, the article's primary author and now an orthopedic

surgeon at Midwest Orthopaedic Group in Peoria, IL, said that some

patients who have performed Pilates prior to joint replacement may

be able to continue with it just two weeks after surgery instead of

taking the traditional physical therapy route.

" We believe it works if the person is dedicated to it, " he said.

Research is lacking

But to date, research on Pilates is slim and many reports on its

effectiveness are anecdotal. Nonetheless, evidence suggests that

Pilates may be helpful in the rehabilitation of hip and knee

arthroplasty patients, at reducing symptoms of low back pain

sufferers, and at helping other individuals recover from injury and

improve their ability to perform activities of daily living.

Pilates instructors also promote the activity's benefits for other

populations, such as women diagnosed with osteopenia or

osteoporosis, pregnant women with back pain, multiple sclerosis

patients, and those who have scoliosis, adhesive capsulitis,

sciatica, or peripheral neuropathy.

Rochenda Rydeard, PT, director of the BET Pilates Centre in Hong

Kong, is the primary author of one of the few controlled studies of

the therapeutic benefits of Pilates. The article was published in

the Journal of Orthopaedic & Sports Physical Therapy in July 2006

and compares a Pilates-based exercise program for low back pain with

usual care. The study was conducted while Rydeard was a graduate

student at the School of Rehabilitation Therapy at Queen's

University in Kingston, ON. Previously, she had worked at a Pilates-

based physical therapy practice and had seen patients report

physical improvements attributed to the exercise.

" We had had consistent excellent clinical outcomes with our patients-

both measured outcomes and patient reports of functional

improvements, particularly with chronic low back conditions, " she

said. " There was no research or published articles at all on Pilates-

based interventions and no evidence to support any reported clinical

outcomes. "

Prescription for back pain?

The study randomly assigned 39 physically active individuals between

the ages of 20 and 55 who had low back pain to receive usual care,

which included seeing a doctor and other healthcare professionals as

necessary, or to a Pilates-based exercise program for four weeks.

Eighty percent of the subjects had experienced low back pain for at

least six weeks and 20% had recurring pain at least twice a year

that was strong enough to restrict their functional activity. Ninety

percent of the subjects had received physical therapy.

The exercise group participants took part in an individualized one-

hour session using specialized Pilates equipment in the clinic once

a week and were assigned to perform a 15-minute home program daily

during the rest of the week. The program was designed to exercise

the deep anteriolateral abdominal muscles, gluteus maximus muscles,

and the lumbar-pelvic region musculature. The control group was

offered free participation in the exercise program after the four-

week study period ended.

The researchers measured significant improvements in average pain

intensity and functional disability in the exercise program group

after four weeks, compared with baseline, as well as after three,

six, and 12 months. After adjusting for pretest measurements, the

exercise group participants rated their pain intensity on the 101-

point Numerical Rating Scale as an average of 18.3 following the

four-week program, compared with 23.0 beforehand, whereas the

control group scored 33.9 at the end of the four weeks compared with

30.4 earlier (Table 1).

The exercise patients' adjusted scores on the Roland-

Disability Questionnaire dropped from 3.1 before the treatment to

2.0 afterward. The control group's scores decreased from 4.2 to 3.2.

The treatment's effects on functional disability appeared to remain

over time, with patients scoring 0.9, 0.4, and 0.9 on the RMDQ at

three, six, and 12 months after completion of the exercise program,

compared with an unadjusted score of 1.7 immediately following the

treatment.

" A modified Pilates approach is helpful as it can help retrain

dysfunctional muscle activation and movement patterns, " Rydeard

said. " The theory is that mechanical and neurological mechanisms

related to the pain or injury can affect muscle firing patterns,

including the ability of specific muscle synergies to stabilize and

control the trunk and spinal segments. "

Rydeard and her colleagues are currently analyzing electromyographic

data from the study to see if muscle activation patterns can be

influenced by Pilates-based training.

Another randomized controlled study published in Europa

Medicophysica in September 2006 found that a form of Pilates was

effective for treating low back pain. Italian researchers assigned

43 patients who had suffered from low back pain without radicular

symptoms for at least three months to either a Back School or a

Pilates-based rehabilitation program. They each participated in

daily one-hour sessions for 10 days in a row in groups of up to

seven patients.

The Back School patients were instructed in postural education

exercises, respiratory education, extension and strengthening

exercises of the paravertebral muscles and lower limbs, mobilizing

exercises for the spinal column, and antalgic postures. The Pilates

participants received postural education; information about finding

neutral position; sitting, antalgic, stretching, and proprioception

improvement exercises; breathing education; mobilization of the

cervical rachis and the scapulohumeral joint; and theoretical

explanations.

The researchers found that both pain intensity, as measured by the

visual analog scale, and disability, as measured by the Oswestry Low

Back Pain Disability Questionnaire, significantly dropped after one

month and remained at those levels after six months in both groups.

VAS scores were recorded at around 7 in the Pilates group and 6 in

the Back School group prior to treatment and at around 4 in both

groups after one, three, and six months. OLPDQ scores started at

around 13 in the Pilates group and 9 in the Back School group and

dropped to around 7 in both groups at one month, with little change

after that.

The Pilates group also showed better subjective response to

treatment (Table 2). This suggests the use of Pilates as an

alternative treatment for nonspecific low back pain.

Pain management

Rehabilitation and pain management experts say that the setup of

Pilates exercises, particularly those involving equipment Pilates

designed, allows pain sufferers to exercise comfortably. However,

controlled studies have not been conducted comparing Pilates with

other treatments for pain, other than back pain.

, an enthusiastic proponent of the system who would like to

see more research conducted on its effects, explained that Pilates

teachers can help patients who suffer from pain to exercise by

adjusting Pilates machines in certain ways.

Fred Redfern, an orthopedist in , NV, who specializes in

sports medicine and total joint replacement, also praises Pilates

for similar reasons. He has found that the trunk strength and

control that he gains from performing the exercises helps to relieve

his low back pain.

" One of the main concepts of Pilates is that it relieves or assists

natural gravitational forces and takes some of the pressure off of

your back, " Redfern said.

He said that some of his patients have spine and hip pain and that

it is hard to determine which part of their body is causing the

problems. Pilates can reduce pain in some patients and help

determine, through strengthening exercises, whether their pain is

secondary to weak trunk muscles.

Pilates can also be helpful for patients who have had a hip or knee

replaced and may be at risk of suffering from back or trunk problems

due to reduced activity, Redfern said.

Age not a barrier

One controlled study, as well as testimony from Pilates

practitioners, demonstrates that the exercise discipline also can

benefit older and more frail individuals.

The study, published in BMC Geriatrics in October 2003, reported on

the participation of acutely ill, hospitalized older adults in a

hospital-based resistance exercise program that incorporated

resistance training and Pilates principles. The researchers randomly

assigned 39 patients older than age 70 who had been recently

admitted to a hospital in Halifax, NS, to take part in the exercise

program or the study's control group, which received passive range-

of-motion exercise.

Participants were required to have been walking prior to admission

and to be able to follow the three-step command on the Folstein Mini-

Mental State Examination. Those who were expected to have a short

length of stay were excluded as were those who had a number of

serious medical conditions.

All patients received usual hospital care, including physical

therapy. The exercise participants exercised three times a week with

a physical therapist until discharge or for a maximum of four weeks.

They performed a program targeting the lower extremities. Exercises,

which included single leg extension, plantar flexion, and

dorsiflexion, were repeated 10 times for a maximum of three sets.

The researchers did not measure the effectiveness of the exercises,

but found that the exercise group completed an average of 71% of the

sessions (which was defined as performing at least 75% of the

exercises). Sixty-three percent of exercise group subjects

participated in more than 75% of their scheduled sessions. The

comparable numbers were 96% and 95% for the passive ROM

participants, indicating that resistance exercise is difficult for

some acutely ill, hospitalized, older patients.

Sherri Betz, PT, on the other hand, teaches Pilates at TheraPilates

in Santa Cruz, CA, to some older clients who are quite dedicated to

their regular exercise routines. At the combination physical therapy

clinic and Pilates studio, Betz specializes in working with women,

including those who are postmenopausal, have been diagnosed with

osteoporosis or osteopenia, suffer from osteoarthritis, have

undergone hip replacement, or are pregnant. One of her clients is an

89-year-old woman with osteoporosis who completes a one-hour session

weekly using Pilates equipment.

Betz said that Pilates can be particularly helpful in improving

posture and preventing further postural changes from occurring in

those with osteoporosis or osteopenia. Body awareness, another

benefit seen, could prevent falls and fractures. In those with

osteoarthritis, performing Pilates can decrease pain and increase

ROM, particularly in the hip area, she said.

However, working closely with a teacher initially-for at least four

or five sessions-before digging into group mat classes is a must for

safe Pilates performance for these older patients, Betz said.

" About 85% of Pilates exercises are contraindicated, " Betz said of

people diagnosed with osteoporosis. Many exercises involve bending

and forward flexion that individuals who have osteoporosis should

not be performing.

Betz said individuals with osteoporosis can participate in group mat

classes by modifying some of the exercises.

Although she would like to conduct randomized controlled studies

regarding Pilates and osteoporosis, Betz for now is documenting

individual cases. Those with osteoporosis or osteopenia are

participating in a Pilates equipment class once a week and a mat

class three times a week. Other than walking three times a week,

participants are told to perform no other formal exercise. Bone

density measurements are being taken for each participant at the

beginning of the study and a year later. Betz said some individuals

have seen bone density gains of 15%.

A function of instruction

While age or physical condition isn't a barrier to safe Pilates

participation for many individuals, both medical practitioners and

Pilates therapists agree that finding a knowledgeable teacher is key.

" The only drawback I see with Pilates for biomechanical conditions

is the lack of training of the therapist, " said. " A well-

trained Pilates teacher can design a successful movement program on

any piece of equipment in a gym or in a pool. "

The length of Pilates instructor training programs varies widely.

Lakis and -Brown advise that individuals seek instructors who

have completed 500- to 1000-hour programs, including courses and

observation, and not just a weekend course.

Back at dharmaspace, Lakis said he will typically work with the

doctor of a patient with a biomechanical condition, such as a

herniated disk, to ensure that the exercise program is properly

tailored to the injury or he will develop a regimen for a

postoperative patient who has exhausted her health plan's therapy

benefits based upon information provided by the physical therapist.

" We can then develop a treatment plan that is really effective, " he

said.